Manor Field Surgery

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. A review found some members of the administration team were overdue appraisals, following this assessment, the provider submitted an action plan showing how these would be caught up on. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Some staff told us they felt that communication within the practice, and how different teams communicated with each other could be improved. The service had an action plan in place with the aim of improving communication. Staff understood their roles and responsibilities. Managers worked with the local community to deliver the best possible care and were receptive to new ideas. There was a culture of continuous improvement with staff given time and resources to try new ideas.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Most staff felt they contributed to the development of the practice vision and strategy. The practice had recently undertaken a staff survey in 2025 which showed that the majority felt they could voice their ideas and opinions in a safe environment. Staff told us that they felt communication at the practice could improve, and also how different teams communicated with each other. This was reflected in the staff survey, following this the provider had implemented an action plan to try and improve communication. This included, ensuring that regular staff meetings were taking place and completing the survey again so that staff could provide their feedback on what was working and what was not.

The practice was aware of the projected increase in the local population and was working with partner agencies to address future challenges.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff told us leaders in the practice were approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the practice. We saw the leadership team tried to work with other practices in the primary care network (PCN) and were engaged in the development of primary care services within the local area. Extended access appointments were available in a neighbouring village, however, the practice identified that some of their patients struggled to access these services. As a result, an extra Advanced Nurse Practitioner was allocated to the practice.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. Staff were given training on freedom to speak up and whistleblowing, staff told us they were aware of how to raise concerns.

The service had established policies and procedures to promote diversity and equality were in place. We observed that staff were encouraged to develop within their roles and were supported in accessing professional development opportunities.

We saw how members of the nursing team were being supported to gain a prescribing qualification.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. The provider had established governance processes that were appropriate for their service. Staff could access all required policies and procedures. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff. However, feedback received from staff showed that they felt that communication could still be improved further. Following a recent staff survey that the provider had completed, they developed an action plan to improve communication across the practice. The provider planned on running the survey again in the future. Staff took patient confidentiality and information security seriously.

A review of staff files showed that some members of the administration team were overdue appraisals. Following the assessment the practice provided an action plan for how these appraisals would be completed and a plan so that appraisals would be aligned and done roughly at the same time each year.

It was difficult for managers to maintain oversight of when staff were due mandatory training. Staff had to notify managers themselves. After the assessment, the provider outlined plans to improve this by introducing new software to give managers better oversight and assurance.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborate for improvement.

The provider worked with other practices within their PCN to offer extended access, and flu and covid vaccination programmes. Due to their patient cohort and the difficulties some of these patients faced being able to travel to neighbouring practices, an Advanced Nurse Practitioner was allocated to work at the practice following discussions with the Integrated Care Board (ICB).

The practice had an active Patient Participation Group (PPG) that met regularly. The PPG were consulted when the practice brought in their total triage model. As a result of feedback from the PPG, one of the triage questions was amended.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The practice had a quality improvement plan in place to help drive improvements in services. As a result of this the practice had recently changed their appointment system to a total triage based system. The practice identified a gap in the skillset of their administration staff, as a result they contracted work to an external document‑management provider. To ensure the quality of work was maintained at a high standard they had regular meetings, logged issues, collaborated on improvements, and developing internal training with the long‑term aim of bringing processes back in‑house.

All staff were encouraged to put forward and test out new ways of working.